Fraud Detection and Avoidance

Daisy implemented its Fraud Detection solution for the dental and drug lines of business during this trial to meet our client’s objectives and to build a business case for enhancing fraud detection and avoidance capabilities.

• Daisy Fraud Detection: Automated AI-based fraud detection system that would identify potential fraud for both historical claims as well as in-process claims before adjudication was completed.

A typical Daisy implementation requires two months to onboard the client’s data and to work with the business operators to understand the client’s existing process and capabilities in claims processing. The client already had a set of fraud flags that were used for fraud detection and had historical labels for previous fraudulent claims and individuals. Over a six month period, Daisy delivered its system which included integrating the clients flags with Daisy’s existing probabilistic rules. Predictive models using the client’s labels were autonomously deployed, fuzzy logic peer analysis of patients and providers was autonomously deployed, and social network analysis of all entities was autonomously deployed.

The client dedicated a single investigator per line of business to work with the Daisy system. The first phase of the trial was a backward-looking review of historical claims using the Daisy system. If sufficient evidence was uncovered in the historical review, a second phase of the trial would be to use the system in an operational test to determine the actual recoveries that can be achieved using the Daisy system.